MEDICARE: ANGEL HOUSE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1710270186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL HOUSE INC

Provider Business Mailing Address
First Line	:	3816 LIBERTY RIDGE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-2902
Country	:	US
Telephone Number	:	757-486-0007
Fax Number	:

Provider Business Practice Location Address
First Line	:	3816 LIBERTY RIDGE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-2902
Country	:	US
Telephone Number	:	757-486-0007
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AMAN MASSAQUOI
Credential	:
Telephone Number	:	757-486-0007

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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Directions to “ANGEL HOUSE INC ” Practice Location

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